Diagnosis: Sore Throat and Fever.
Treatment: Inpatient Hospital Admission.
The proposed inpatient hospital admission was not medically necessary.
The plan's decision is upheld.


This female patient presented with three days of weakness associated with headache, body aches, cough, fevers and sore throat. The patient's vital signs included: temperature 37.5(maximal temperature 103.5), pulse 108, respiratory rate 16, blood pressure 98/64, and oxygenation saturation 95%. The patient's exam was remarkable for pharyngeal erythema and cervical tenderness. The complete blood count and comprehensive metabolic panel were unremarkable. The patient's lactic acid was 0.69, COVID was negative, and Influenza-A was positive. The patient's chest x-ray showed no acute disease. Electrocardiogram (EKG) showed sinus tachycardia.

The patient was admitted on with sepsis due to influenza. The plan of care included intravenous antibiotics and intravenous (IV) steroids. Tamiflu was started. The patient was discharged.

This patient was admitted with Influenza-A. She did not have altered mental status. She was hemodynamically stable with a fever. She had normal oxygenation. Labs were remarkable for elevated lactic acid level. The patient did not have end organ failure or an active comorbid condition. She did not have bacteremia. She did not require intravenous antibiotics at an inpatient level of care. She had not failed an observation level of care. Inpatient hospital admission was not medically necessary.
The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The proposed treatment was not medically necessary.